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How does culture shape the expression of mental illness or anamolous mental states? I've explored that questions several times at Neuron Culture, sometimes provoking sharp objections to the idea that culture has any effect at all on the expression of psychosis — some people are just crazy, the response goes, and culture has little or nothing to do with it. Some of that response was due to poor argument on my side; I tried to make it move substantive in Batman Returns: How Culture Shapes Muddle Into Madness.

In Hearing Voices in Accra and Chennai, a recent talk broadcast at the Culture Mind Brain conference, Stanford's Tanya Luhrmann looks at roughly this same issue through another prism: that of the voices people with schizophrenia sometimes hear. It shows yet another example of how both the experience of what we call schizophrenia and other people's response to it vary by culture.

A couple weeks ago I was delighted to find a more comprehensive piece by Luhrmann at Wilson Quarterly, Beyond the Brain, in which she looks at how mainstream psychiatry's biological model of schizophrenia is starting to recognize this heavy influence of culture, with increasing recognition of schizophrenia as a "biocultural" phenomenon. Luhrmann's opening account of one particular patient, Susan, shows how different responses from culture can shape the course of schizophrenia, even within the U.S.:

Susan was a success story. She was a student at the local community college. She had her own apartment, and she kept it in reasonable shape. She did not drink, at least not much, and she did not use drugs, if you did not count marijuana. She was a big, imposing black woman who defended herself aggressively on the street, but she had not been jailed for years. All this was striking because Susan clearly met criteria for a diagnosis of schizophrenia, the most severe and debilitating of psychiatric disorders. She thought that people listened to her through the heating pipes in her apartment. She heard them muttering mean remarks. Sometimes she thought she was part of a government experiment that was beaming rays on black people, a kind of technological Tuskegee. She felt those rays pressing down so hard on her head that it hurt. Yet she had not been hospitalized since she got her own apartment, even though she took no medication and saw no psychiatrists. That apartment was the most effective antipsychotic she had ever taken.

[R]esearch in public attitudes in fact shows a steep increase in the affirmation of biomedical causal beliefs regarding schizophrenia over the past two decades. (Climbing not only in the 90s, but every year since.) Georg Schomerus and colleagues’ (2012) important recent meta-analysis helpfully aggregates this data. Not only have biomedical beliefs and aetiological attributions increased dramatically over the last two decades; social acceptance and inclusion, in parallel, has declined even further.

I find this a bracing pair of reads. The current jabbering about the relationship between madness and violence might improve if more people were familiar with the ideas raised in these essays. Both essays might strike newcomers to the discussion as dense at points, and the differences between the two authors obscure or academic, as Luhrmann and N disagree on where we are in the pendulum swing between environmental and biological causes of madness. But it seems safe to say they would agree that — as the recent Culture, Mind, Brain conference suggests — there's more attention now to seeing how environment (including culture) and biology work together, and less on an either-or explanation.

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Edits: Jan 15, 2013: Corrected a few typos, changed a muddy phrase or two, and removed a couple redundancies.